We get it. You have a nagging pain in your back that just won’t go away, so you go see your doctor, who sends you for an X-ray. Unfortunately, the X-ray doesn’t show a thing, so the next step might be a CT-scan or even an MRI, and you may even have to see a specialist depending on the test results.
You think you’re all set, but then the doctor says, “We’ll call you to set up an appointment after we get prior approval from your insurance company.”
Wait. What? You think, “I can barely stand up and now I have to go through this red tape?”
Yes, you probably do.
Community Health Options understands that getting medical care is nerve-wracking enough, so you won’t need a referral for the specialists, even though the specialist may require one from your doctor. But Members do need Prior Approvals for certain services and prescriptions before getting treatment (Prior Approvals are also sometimes called Prior Authorization, Precertification or Preauthorization).
While it might seem like getting approval delays care, Community Health Options, as a nonprofit insurer, uses Prior Approvals to understand its Members needs and to facilitate care. Clinicians rely on evidence-based care guidelines to approve the care Members need, while protecting against the care they don’t. Importantly, approval ensures that a Member’s health plan will cover the service or procedure.
Community Health Options Chief Medical Officer Dr. Lori Tishler calls it “utilization management with heart. Our goal is to get someone what they need, so we’re constantly looking for ways to make things easier for patients and providers.”
When "No” means “Yes”
In some cases, clinicians at Community Health Options may even suggest more care than the initial request. For example, a request for a certain kind of outpatient behavioral health care was denied because the Community Health Options team saw a need for inpatient care and worked with the provider to get that higher level of care delivered.
In almost every case, the company responds to urgent requests within 24 hours and more routine requests within 72 hours, but usually less. Requests may be denied if clinicians at Community Health Options need more information about the need for a certain procedure.
And in 2023, the company dropped Prior Approval requirements for about 5,000 codes primarily across three categories—ultrasounds, obstetrics ultrasounds and services related to treating fractures. A code review committee continues to review and revise Prior Approval requirements.
A right to appeal
Members and providers always have the right to appeal a Prior Approval decision, whether for a medical benefit or prescription. In many cases, additional information helps to move things along, and sometimes providers will talk to an independent doctor for a final decision about the best solution.
Members with questions or concerns about Prior Approval can call the Community Health Options’ Maine-based Member Services team number on the back of their Member ID card from 8 a.m. to 6 p.m., Monday through Friday.
Health insurance metals help people understand the amount of cost sharing that goes on between the plan holder and the insurance company in any given plan. (Need a refresher on how these costs work? Check out our health insurance lingo blog post here!)
Remember that the exact amount of cost sharing can vary from plan to plan. And at each metal level, you’ll pay a different percentage of total yearly costs of your care, while your insurance company will pay the rest. Total costs include premiums, deductibles, and out-of-pocket costs like copayments and coinsurance.
As a rule, the less the insurance company pays in cost sharing, the lower the cost of the plan. So, Bronze plans typically have the lowest monthly premium costs and highest costs when you need care. Monthly premium costs generally increase according to metal levels. Silver, Gold, and Platinum cost more each month in premium payments but will have lowers costs when you need care. While your monthly premium price is often the top consideration when purchasing health insurance, it’s important to consider the deductible and cost sharing as well, since these two factors can impact the total amount of out-of-pocket healthcare costs you might incur in a plan year. The total cost of care is what really matters.
When choosing a plan, you’ll want to think about how much you (and your dependents) are likely to use your insurance coverage. Consider things like how often you see a doctor, what medications you take, and whether you foresee scheduling any elective surgery during the year to come. If you think you’ll use your healthcare plan frequently or have prescription medications you take regularly, you might want to consider a higher metal level that offers lower deductibles and makes your costs easier to predict (like a Gold or Platinum plan). If you don’t expect needing many healthcare services, a lower-premium/higher cost share plan might be a better fit.
One thing that’s important to know is that ALL Community Health Options’ plans in ALL metal categories offer $0 cost share preventive care, including yearly wellness checks. Many plans also offer an array of low-to-no-cost benefits that help offset many healthcare expenses (like wellness visits, prescription benefits, and vaccines), even for people with chronic conditions. All non-HSA plans offer Amwell® urgent care telehealth visits with $0 cost sharing. So, whether you choose Bronze, Silver, Gold or Platinum, you can find a plan that meets your budget and your needs while giving you peace of mind and helping to keep you and your family healthy.
